What to do if a patient has subjective pain but normal Ultrasound (USG) findings and no significant medical history?

Management of Subjective Pain with Normal Ultrasound Findings

When a patient presents with subjective pain but has normal ultrasound findings and no significant medical history, a thorough pain assessment and symptomatic treatment should be initiated, with consideration for further diagnostic evaluation only if pain persists or worsens.

Pain Assessment Approach

When faced with subjective pain complaints without objective findings on imaging:

1. Detailed Pain Characterization:

   • Location: Determine if pain is focal or diffuse
   • Quality: Sharp, dull, burning, throbbing
   • Timing: Constant, intermittent, related to activities
   • Severity: Using a numerical rating scale (1-10)
   • Aggravating/alleviating factors: What makes it better or worse?
   • Impact on daily functioning and quality of life 1

2. Physical Examination:

   • Focused examination of the painful area
   • Assessment for referred pain from adjacent structures
   • Evaluation of musculoskeletal components (trigger points, muscle tension)

Management Algorithm

First-Line Approach:

1. Reassurance: Explain that normal imaging findings are favorable and rule out serious pathology
2. Symptomatic Treatment:
   • Over-the-counter analgesics (acetaminophen, NSAIDs) for short-term pain relief
   • Local measures: heat/cold application, topical analgesics
   • Physical therapy for musculoskeletal components if appropriate

If Pain Persists (>10 days):

1. Re-evaluation of symptoms and examination findings 2
2. Consider alternative diagnostic approaches:
   • Different imaging modality if clinically indicated
   • Evaluation for referred pain sources
   • Assessment for functional pain disorders

Special Considerations by Body Region

Abdominal Pain

For nonlocalized abdominal pain with normal ultrasound:

• Consider CT with IV contrast if pain persists, as it can screen for a broader range of pathologies 3
• In pregnant patients, MRI without contrast may be appropriate as a next step if ultrasound is nondiagnostic 3

Breast Pain

For breast pain with normal ultrasound:

• If focal and noncyclical: Consider mammography for women ≥30 years 4
• If diffuse or cyclical: No additional imaging beyond routine screening is typically needed 3
• Supportive measures including well-fitted bra and NSAIDs are first-line treatments 4

Shoulder Pain

For traumatic shoulder pain with normal ultrasound:

• Consider MRI if pain persists, especially for suspected soft tissue injuries 3
• Noncontrast MRI may be preferred in acute settings as joint effusion can help assess intra-articular structures 3

Pitfalls to Avoid

1. Dismissing subjective pain: Pain is a subjective experience and should be taken seriously even without objective findings 5, 6

2. Overreliance on imaging: Normal imaging does not rule out all causes of pain; functional pain syndromes and early pathology may not be visible 7

3. Premature cessation of evaluation: If pain persists or worsens despite initial management, further evaluation is warranted 2

4. Missing referred pain: Up to 15% of localized pain cases may originate from other structures 4

5. Failure to document informed consent: Proper documentation of treatment discussions is essential, especially when invasive interventions are considered 8

By following this structured approach to subjective pain with normal imaging, clinicians can provide appropriate care while avoiding unnecessary testing or dismissal of legitimate symptoms.